O T H E R F E AT U R E S Checklists: The Good, the Bad, and the Ugly Ellen S Deutsch, MD, MS, FACS, FAAP, CPPS Are checklists helpful? A colleague recently confided to me that she struggles to use a Editor, Pennsylvania Patient Safety Advisory one-size-fits-all checklist, required by her organization, for her specialized procedures. Medical Director, Pennsylvania Patient Safety Authority The usefulness of checklists seems intuitive, and checklists have been mandated in many healthcare settings. However, these tools have both fierce advocates and determined detractors, so perhaps the devil is in the details of checklist creation and implementa- tion. Even checklist promoters, including Atul Gawande, author of “The Checklist Manifesto,”1 acknowledge both the potential and the limitations of checklists. A checklist is “typically a list of action items or criteria arranged in a systematic man- ner.”2 But the term “checklist” can encompass a variety of formal and informal cognitive aids designed for a variety of functions: to support recall of vital information, enhance communication, activate team members, share situational awareness, and anticipate needs and hazards for individual patients.1,3,4,5 Checklists can also be designed to docu- ment or audit processes—as lists of items requiring attention or verification, often in a sequential manner (“challenge-do-respond”), or as summations or “clean up” to confirm that the team has completed all of the requisite tasks (“do-verify”).4 Checklists in health- care may be used to document compliance with protocols or policies and are often accompanied by the refrain that “if it’s not documented, it didn’t happen;” in contrast, Verdaasdonk and coauthors note that “checklist items in aviation are not marked when completed.”4 The Good. Checklists have been used successfully and found to be effective in several high-hazard industries, including healthcare in specific settings.2,6 Checklists can be used to reduce variability and improve performance3,7 and may be most beneficial during urgent or emergent medical care8 or when treating unusual conditions. They may ensure the predictability3 and completeness of selected processes. Winters and colleagues point out that checklists democratize knowledge, thereby improving the reliable translation of information and reducing the risk of miscommunication among members of healthcare teams.7 The Bad. A systematic review of safety checklists for use by medical care teams in acute hospital settings revealed limited evidence of effectiveness,9 and compliance with check- lists has been only moderate.10 Checklists targeting novices tend to be thorough but may penalize experts unfairly for being more direct or efficient.11 Checklists may create dependence, which can interfere both with professional judgment and the objectivity of decision-making.2 Completing checklists might also distract participants from recog- nizing or communicating important information about specific patients if it does not fit easily into the pre-set categories included in the checklist. The Ugly. Checklists have the potential to create a negative impact.12 They can be too long, hard to use, or impractical;1 they may penalize efficiency,11 decrease participant satisfaction,13 create “clumsy roadblocks;”3 and contribute to “checklist fatigue.”2,3 The greatest danger may occur when checklists are completed in a rote, perfunctory, or disengaged manner; creating a false veneer of safety without meaningful attention to potential hazards. Creating and implementing helpful checklists involves both science and art. There is an iterative relationship between the content of the checklist and its interactions with the ambient healthcare system. The qualities of efficiency, adaptability, thorough- ness, standardization, predictability, practicality, and customization for relevance may compete with each other.3,5 The appropriate content emerges from trade-offs about the purpose, the users, and the use setting. Once the desired content is determined, whether the checklist is presented in a paper or electronic format, design principles Page 122 Pennsylvania Patient Safety Advisory Vol. 13, No. 3—September 2016 ©2016 Pennsylvania Patient Safety Authority can be applied to the visual layout to should be considered.4 Involving users in Finally, even if a carefully crafted and enhance readability. Established prin- the checklist’s development can improve thoughtfully implemented checklist ciples can help address the number of both relevance and buy-in, and pilot test- approaches perfection, will it have the items included, the sequence in which ing in situ allows refinement based on same relevance over time? Several authors items are listed, how items are grouped, information gained in actual work circum- recommend periodic review of check- text fonts, colors, bulleted lists, and stances. How does the checklist fit the lists.4,8,15 Attention to both the small other factors.1,3,4,7,14 Adding a “not appli- unique characteristics of the healthcare details and the big picture of creating cable option” to “yes or no” formats can facility? How should the checklist fit into and implementing checklists can be used improve relevance.12 Concluding team the participants’ workflow? How can ease to optimize their helpful aspects and checklists with an open-ended invitation of access be accomplished? How can we minimize counterproductive components. for any team member to speak up may ensure sufficient, but not excessive, redun- Applying both science and art to checklist elicit additional information or concerns dancy with other processes?12 Can we creation and implementation can help that can benefit the safe and compassion- include branching logic and decision sup- resolve the devil in the details. ate care of a patient. port to make both paper and electronic Beyond creating the checklist content and checklists more intelligent and adaptable?3 display, the context of implementation NOTES 1. Gawande A. The checklist manifesto: How to 7. Winters BD, Gurses AP, Lehmann H, 12. Fourcade A, Blache J, Grenier C, et get things right. New York, NY: Henry Holt et al. Clinical review: checklists - trans- al. Barriers to staff adoption of a sur- and Company; 2011. lating evidence into practice. Crit Care gical safety checklist. BMJ Qual Saf 2. Hales BM, Pronovost PJ. The checklist- 2009;13(6):210. 2012;21(3):191-97. -a tool for error management and 8. Ziewacz JE, Berven SH, Mummaneni 13. Calland JF, Turrentine FE, Guerlain S, performance improvement. J Crit Care VP, et al. The design, development, et al. The surgical safety checklist: lessons 2006;21(3):23135. and implementation of a checklist for learned during implementation. Am Surg 3. Grigg E. Smarter clinical checklists: How intraoperative neuromonitoring changes. 2011;77(9):1131-37. to minimize checklist fatigue and maxi- Neurosurg Focus 2012;33(5):E11. 14. Gwynne JW, III, Kobus DA. Documenta- mize clinician performance. Anesth Analg 9. Ko HCH, Turner TJ, Finnigan MA. Sys- tion. In: Weinger MB, Wiklund ME, 2015;121(2):570-73. tematic review of safety checklists for use Gardner-Bonneau DJ (eds.). Handbook of 4. Verdaasdonk EG, Stassen LP, Widhias- by medical care teams in acute hospital human factors in medical device design. Boca mara PP, Dankelman J. Requirements for settings--limited evidence of effectiveness. Raton FL: CRC Press; Taylor and Francis the design and implementation of check- BMC Health Serv Res 2011;11:211. Group; 2011:153-199. lists for surgical processes. Surg Endosc 10. Rydenfalt C, Ek A, Larsson PA. Safety 15. Federico F. Avoiding checklist fatigue: 2009;23(4):715-26. checklist compliance and a false sense of Interview with Dr. Thomas Varghese. 5. Zuckerman SL, Green CS, Carr KR, et al. safety: new directions for research. BMJ Institute for Healthcare Improvement Neurosurgical checklists: a review. Neuro- Qual Saf 2014;23(3):183-186. – Patient Safety [blog]. Updated 2013 surg Focus 2012;33(5):E2. 11. Gerard JM, Kessler DO, Braun C, et Nov 1 [accessed 2016 Jul 13]. http:// al. Validation of global rating scale and www.ihi.org/communities/blogs/_lay- 6. de Vries EN, Prins HA, Crolla RM, et al. checklist instruments for the infant lum- outs/ihi/community/blog/itemview. Effect of a comprehensive surgical safety bar puncture procedure. Simul Healthc aspx?List=0f316db6-7f8a-430f-a63a- system on patient outcomes. N Engl J Med 2013;8(3):148-154. ed7602d1366a&ID=21. 2010;363(20):1928-37. Vol. 13, No. 3—September 2016 Pennsylvania Patient Safety Advisory Page 123 ©2016 Pennsylvania Patient Safety Authority PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 13, No. 3—September 2016. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. Copyright 2016 by the Pennsylvania Patient Safety Authority. This publication may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration provided the source is clearly attributed. This publication is disseminated via e-mail. 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